Effects of a life-skills-based prevention program on self-esteem and risk behaviors in adolescents: A pilot study

Risk behaviors among young people are a major social and public health issue. This study aims to assess the impact of a life-skills-based prevention program (called Mission Papillagou) on self-esteem, well-being, and risk behaviors among adolescents.

Moulier et al BMC Psychology (2019) 7:82 https://doi.org/10.1186/s40359-019-0358-0 RESEARCH ARTICLE Open Access Effects of a life-skills-based prevention program on self-esteem and risk behaviors in adolescents: a pilot study Virginie Moulier1,2*, Hélène Guinet1, Zorica Kovacevic3, Zohra Bel-Abbass3, Yacine Benamara3, Nadhirati Zile3, Arezki Ourrad1, Pilar Arcella-Giraux4, Emmanuel Meunier5, Fanny Thomas1 and Dominique Januel1 Abstract Background: Risk behaviors among young people are a major social and public health issue This study aims to assess the impact of a life-skills-based prevention program (called Mission Papillagou) on self-esteem, well-being, and risk behaviors among adolescents Method: In a two-arm controlled study involving 520 school pupils aged between 10 and 15 years old, participants taking part in the prevention program (the Papillagou group) were compared to pupils who did not take part (the control group) Two assessment sessions were performed, one at baseline, and one after either the Mission Papillagou program (Papillagou group) or usual lessons (control group) Participants self-reported on their selfesteem, well-being, behaviors, interests and opinions Results: The Mission Papillagou program significantly improved Self-Esteem scores (ηρ2 = 035) Well-being (Cramér’s V = 14) and mood (“feeling of depression”: Cramér’s V = 503; “feeling hopelessness about the future”: Cramér’s V = 357; “waking up at night”: Cramér’s V = 343) also improved in the Papillagou group compared to the control group Regarding risk behaviors, the prevention program produced a decrease in the frequency of insults (Cramér’s V = 267) and rumor-spreading (Cramér’s V = 440), and a change of opinion toward the possibility of smoking an electronic cigarette in the future (Cramér’s V = 372) Conclusion: This study suggests that life-skills-based risk prevention programs are effective Keywords: Prevention, Life-skills, Risk behaviors, Self-esteem, Adolescent Background Adolescence is a crucial period of human development, characterized by psychological, biological and behavioral changes, the establishment of self-identity, and an increase in risk behaviors These risk behaviors are defined as ways of acting that are seen as potentially damaging to the health, such as violence, school bullying, and consuming toxic substances (tobacco, cannabis, alcohol, etc.) A 2013/2014 collaborative international survey by the World Health Organization reported epidemiological data about risk behaviors in middle-schoolers, aged from * Correspondence: vmoulier@gmail.com Unité de Recherche Clinique, EPS Ville Evrard, Neuilly-sur-Marne, France Service hospitalo-universitaire de psychiatrie adulte, CH du Rouvray, Sotteville-lès-Rouen, France Full list of author information is available at the end of the article 11 to 15, in 42 countries across Europe and North America [1] Its findings stated that risk behaviors occurred from the beginning of adolescence (11 years old) and their prevalence could increase with age In France, the number of adolescents who smoke tobacco at least once a week increased from 1% (for boys and girls) at 11 years old to 18% (for boys) and 20% (for girls) at 15 years old Regarding alcohol use, 1% of female and 4% of male 11-year-old adolescents reported drinking alcohol at least once a week This figure reached 8% among female and 16% among male 15-year-olds Moreover, 6% of 15-year-old females and 7% of 15-year-old males reported their first experience of being drunk at age 13 or younger With regards to cannabis use, France is at the top of the list of countries: 26% of female and 29% of male 15-year-olds reported to have consumed cannabis © The Author(s) 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated Moulier et al BMC Psychology (2019) 7:82 [1] Regarding interpersonal risk behaviors, 7% of female and 13% of male 13-year-olds indicated having bullied other children (compared with 6% of female and 8% of male 11-year-olds), and 9% of female and 11% of male 13-year-olds reported having been bullied However, physical confrontations tended to become less frequent from 11 to 13 years old: 20 to 12% for males and to 6% for females Finally, this survey highlighted that risk behaviors are major social and public health problems among young people Indeed, risk behaviors induce adverse physical and mental health consequences in later adolescence or adulthood, including poor general health, addiction, anxiety, depression, and suicidal ideation [2– 5], as well as the possibility of brain damage [6] The development of risk behaviors from early adolescence could be explained by an increase in sensationseeking during puberty, due to a remodeling of the brain’s dopaminergic system, which is involved in reward and motivation processing [7] This sensation-seeking may be modulated by various factors, which either exacerbate or protect against risk behaviors A psychosocial framework has been suggested to understand the development of risk behavior in adolescence [8] This study broke down risk and protective factors into five domains: biological/genetics, social environment, perceived environment, personality, and behavior According to this framework, low selfesteem, poverty, or poor school work, are among the risk factors promoting risk behaviors Conversely, having a cohesive family, placing a high value on health and/or involvement in school, are protective factors Appropriate primary prevention programs may help prevent the initiation and development of risk behaviors from early adolescence According to a report on the prevention of risk behaviors at schools by the Institut National de Prévention et d’Education de la Santé (INPES, France) [9], the most effective interventions prioritize the active and interactive participation of pupils, either through role-play or practical work on emotions These methods are not limited to the mere transmission of information, and are based on the development and strengthening of life skills Life skills are defined as abilities that enable individuals to deal effectively with the demands and challenges of everyday life, such as problem solving, critical thinking, empathy, interpersonal skills, and coping with both emotions and stress [10] Their acquisition promotes positive mental well-being, better relationships, and healthier behaviors It also contributes to developing protective factors against risk behaviors, such as self-esteem Self-esteem is defined as the overall appraisal that a person makes of his/her own worth, and represents a critical component of mental health [11] Low self-esteem is related to risk behaviors such as delinquency and antisocial behaviors in 11- and 13-year-old adolescents [12] Moreover, 11-year-olds with lower self-esteem are more likely to display aggressive behavior at the age of 13 Page of 10 Low self-esteem also predicts the onset of smoking [13] and toxic substance consumption, including marijuana, crack, or cocaine [14] Life-skills-based interventions must be adapted, as closely as possible, to their target populations The most effective intervention programs for children are those that take place in the school environment, as early as possible in the development of risk behaviors [15] In addition, Velasco et al highlighted the importance of implementing prevention programs in middle schools before adolescents begin experimenting with drugs [16] However, in France, finding time during the school curriculum to arrange these prevention programs is often a challenge Some effective prevention programs are particularly time-consuming, as they consist of to 15 sessions per year [16] Since 2012, a life-skills-based program called Mission Papillagou has been implemented in several schools that are based in economically disadvantaged Parisian suburbs Mission Papillagou aims to reinforce young teenagers’ self-esteem, to improve the atmosphere in the classroom, to prevent risk behaviors, and to develop interpersonal skills This program promotes abilities such as: (i) solving problems and making decisions; (ii) communicating effectively and being socially comfortable; (iii) thinking creatively and critically; (iv) empathizing, and becoming aware of one’s emotions; and (v) coping with stress and being self-aware Improving life skills could raise selfesteem among young people, and could constitute a protective factor against risk behaviors Based on a science-fiction story, Mission Papillagou consists of a set of group activities which are performed over three separate three-hour sessions (9 h in total) over weeks The different activities, their duration and the life skills that are promoted during each session are described in Table The first session focuses on harmful behaviors (influence, manipulation, spreading rumors), the second session on the importance of cooperating within a group, and the third session on confidence and expressing feelings The program is administered by six facilitators (one educator-supervisor and five nursing students) who have been trained in the delivery of the program Each session is divided into two steps The first step is a role-play game with a series of puzzles to solve in small groups (five or six pupils), each group being supervised by a nursing student The second step, led by the educator, consists of debates based on the topics covered during the first step’s activities Promoting autonomy and empowerment, Mission Papillagou encourages children to experience a series of situations or to solve problems themselves The facilitators help children to develop their own preventive measures Since 2012, 95 classes, i.e 2355 pupils, in the SeineSaint-Denis district (an economically challenged suburb, north-east of Paris) have taken part in this program Moulier et al BMC Psychology (2019) 7:82 Page of 10 Table Characteristics and components of Mission Papillagou program Day Day In small groups Activity With all pupils of class In small groups Activity Activity 50 Activity Duration 45 45 55 Content Social pressure Debate: how Gender to identify and prevent behaviors that affect social life; how to control impulsivity Rumor Day Life skills Critical thinking Coping with Critical thinking, and empathy stress and empathy, coping emotion with stress and emotion With all pupils of class In small groups Activity Activity 50 55 50 50 Coping with frustration and anger Debate: how to Encouraging Benefits of develop trusting others being a child, relationships and benefits of manage emotions being an adult Critical Relationships, Empathy, thinking coping with relationships, and empathy stress and coping with emotion stress and emotion Relationships Selfand selfawareness awareness With all pupils of class 55 Debate: how to support each other, avoid risk behaviors, and deal with adolescence Empathy, relationships, and selfawareness Notes Each session started with an introduction of 25 (Day 1), or 15 (Day and Day 3) Mission Papillagou therefore needed to be evaluated to highlight its impact on risk behaviors in adolescents The aim of this study was to examine the effectiveness of Mission Papillagou on the self-esteem, well-being and risk behaviors of young adolescents, compared to a control group who did not take part in the program Methods Participants The inclusion criteria were: (i) being pupils from sixth- or seventh-grade classes from four middle schools in two economically disadvantaged neighborhoods of Seine-Saint- Fig Flow diagram Denis (a suburb of Paris) who volunteered to participate in the Mission Papillagou program, (ii) being between 10 and 15 years old, and (iii) reading and writing French well enough to complete the questionnaires As shown in Fig 1, 520 pupils were considered eligible for the study, in which a total of 22 sixth- and seventh-grade classes took part In total, 22 sixth- and seventh-grade classes were assessed All children agreed to participate in the program and assessments The program consisted of some role plays, and it took place during school hours The children’s parents were all in favor of having their children participate in a program that could help reduce risky behaviors Moulier et al BMC Psychology (2019) 7:82 The research protocol was approved by each school principal Parents and children received clear, accurate and detailed information about the protocol, and gave written consent to participate Data confidentiality was guaranteed by an identification number For ethical reasons, the Mission Papillagou program was offered to the control group following the end of the study (the program occured in the months following the assessment sessions or the year after) Study design A two-arm controlled trial was conducted Nine sixthgrade classes and eight seventh-grade classes from three middle schools made up the Papillagou group (who received the prevention program); three sixth-grade classes and two seventh-grade classes from the other middle school made up the control group (who did not receive the program) It was necessary that the control group came from a different (albeit socio-economically similar) middle school, to prevent the effects of Mission Papillagou from spreading to other classes through time shared outside of the classroom by the pupils Page of 10 Prior to implementing the program, the MMPCR organized a six-day training course for the nursing students, which included: i) a presentation of the Mission Papillagou program (half a day); ii) a description of its content and practical application through role-play games (five half days); iii) focusing on the problem of violence in schools, including how to prevent it (two half days); iv) focusing on addictive behaviors and their prevention (half a day); v) development of life skills (two half days) Each session ended with a debriefing In addition to this training course, when the Mission Papillagou program was carried out in schools, an APCIS educator was on hand to help the nursing students implement the program correctly Assessments At baseline, and after the two-week Mission Papillagou program/lessons-as-usual, self-esteem, well-being, behaviors, interests and pupils’ opinions were assessed through self-reporting The assessments took place at school, and lasted for around h each time Primary outcome measure: self-esteem assessment Procedure Two assessment sessions were performed: one session at baseline (both groups) and one session after either the Papillagou program (Papillagou group) or lessons as usual (control group) The second session took place between weeks and month after the end of the program (depending on school holidays) On average, 43 (±21) days separated the two assessments The evaluations consisted of self-questionnaires and did not require the help of adults to be filled in To avoid bias, the questionnaires were handed out to participants by someone other than the educator who administered the program when possible This was a member of APCIS (Accueils Préventions Cultures: Intercommunautaire et Solidaire, apcis@wanadoo.fr, an association involved with specially adapting the Mission Papillagou program for middle schools) Data was captured on a computer by two members of a research team (from Unité de Recherche Clinique de Ville-Evrard) who also did not administer the program Prevention program The Mission Papillagou prevention program was specifically adapted for middle schoolers by APCIS and MMPCR (Mission Métropolitaine de Prévention des Conduites Risque) from a program called Mission Papillagou and Croc’Lune’s Children, which was created in 1997 by the National Association for the Prevention of Alcoholism and Addiction in collaboration with The Swiss Institute for the Prevention of Alcohol and Drug Problems [17] The adapted program was administered by an APCIS educator, along with five nursing students Self-esteem was measured with the Self-Esteem Scale of Toulouse (ETES), a validated self-administered questionnaire of 60 items [18] Participants were asked to rate their agreement using a five-point Likert scale (from “totally agree” to “totally disagree”) Five sub-categories were distinguished: Emotional Self, Social Self, Scholarly Self, Physical Self, and Future Self The Emotional Self score represented the participants’ control over their emotions and impulses The Social Self score represented interactions with others (family, friends, etc.), and the feeling of being recognized socially The Scholarly Self score represented attitudes, behavior and school performance The Physical Self score referred to how each individual believed their physical appearance was viewed by others, how they viewed their own physical appearance, their own sports skills, and their own attractiveness The Future Self score referred to how each child saw themselves in adulthood The sum of these five scores constituted the total ETES score Regarding its psychometric characteristics, this scale exhibited a good internal consistency in the whole sample (α = 0.81) and in the two samples (Papillagou group: α = 0.80; control group: α = 0.84) Secondary outcome measures Well-being assessment An unvalidated Visual Analog Scale (VAS) was used to measure the adolescents’ sense of well-being The VAS comprised of a horizontal line, 10 cm in length, anchored by two well-being verbal descriptors, from “I feel awful” on the left, to “I feel very well” on the right The children were instructed to draw a cross on the line Moulier et al BMC Psychology (2019) 7:82 Health and risk behavior assessment A selfadministrated questionnaire called “PEPS”, which had been adapted from a French national survey by Choquet & Ledoux [19] and a study by Choquet & Lagadic [20], was used to investigate health and risk behaviors This questionnaire consisted of assertions, divided into six sections: i) social and educational situation; ii) relationships; iii) mental and physical health (for example, “in the last two weeks, I have felt depressed” or “in the last two weeks, I have had headaches”); iv) risk behaviors, including toxic substance consumption (for example, “have you ever smoked cigarettes? If so, how many cigarettes a day/ a week/ a month?”), anti-social behaviors such as absenteeism (for example, “in the last two weeks, I have skipped school”), physical violence (for example, “in the last two weeks, I have been in a fight”), and verbal violence (for example, “in the last two weeks, I have spread a rumor” or “in the last weeks, I have insulted someone in school); v) activities and interests; and vi) opinions Subjects had to rate the frequency of each assertion Sample size Since the threshold of discrimination for changes in health-related instruments appears to be approximately one half a Standard Deviation (SD) [21], the sample size needed to detect a meaningful difference on the SelfEsteem Scale of Toulouse (ETES) between the two groups was 92 subjects per group, with a 90% power (alpha = 0.05, two-tail) Considering the high rate of absenteeism in these schools (20 to 25%), we included at least 123 subjects per group Given the direct benefits of the Mission Papillagou program for children, the number of subjects included in the Papillagou group was greater than the minimum number of participants required Statistical analyses Statistical analyses were performed with SPSS®25 Software (Chicago, IL) Data entry on a computer was done by two people (one reading the data aloud and the other inputting it) Then, the accuracy of the data entry was randomly checked Only data from pupils who completed the program was included in the analyses (per-protocol analysis) A mixed analysis of variance (ANOVA) was performed to analyze Total Self-Esteem score, and a multivariate analysis of variance (MANOVA) with bootstrapping was performed to analyze the dimensions of Self-Esteem (emotional, social, scholarly, physical and future self) Well-being was transformed into a categorical variable and was analyzed with a chi-squared test Regarding the PEPS questionnaire, the categorical variables were recorded as binary (yes/no) variables in terms of improvement at the second assessment compared to the first The proportion of subjects Page of 10 who improved was compared between the two groups using the chi-squared test If the criteria for using the chisquared test were not met, Fisher’s exact test was used Effect sizes were measured through partial eta squared (ηρ2) for mixed ANOVA and MANOVA (0.0099 (small); 0.0588 (medium); 0.1379 (large)) and Cramér’s V for chi-squared or Fisher’s exact tests (for one degree of freedom: 0.1 (small); 0.3 (medium); 0.5 (large)) Benchmarks to define small, medium and large have been suggested by Cohen [22] Results Participant characteristics The data from 413 pupils who participated in all assessments was analyzed: 317 in the Papillagou group (who took part in the Mission Papillagou program), and 96 in the control group (who did not take part in the program) The participants were aged between 10 and 15 years old: mean (Standard Deviation, SD) age = 11.82 (.86) in the Papillagou group; mean (SD) age = 11.83 (.88) in the control group (no significant difference between groups: t410 = 1.011; p = 313) In terms of gender distribution, there were 179 males/138 females in the Papillagou group and 47 males/49 females in the control group (no significant difference between groups: X2(1) = 1.417; p = 234) Regarding toxic substance consumption in the whole sample at the baseline, 16.5% of the pupils had already drunk alcohol (boy-girl ratio = 58/42%), 11.1% had already tried smoking tobacco (boy-girl ratio = 67/ 33%), 8.5% had already tried electronic cigarettes (boy-girl ratio = 71/29%) and 3.4% had already tried cannabis (boygirl ratio = 69/31%) Among the adolescents who had already consumed toxic substances, 2.7% smoked cigarettes at least once a week (n = 11), 8.2% smoked hookah at least once a week (n = 33), 4.5% smoked electronic cigarettes at least once a week (n = 18), and 0.5% smoked cannabis at least once a week (n = 2) 2.5% of the pupils also reported regularly drinking alcohol (n = 10) Regarding interpersonal risk behaviors, 19.8% reported having skipped school at least once in the previous two weeks (n = 79), 44.7% had insulted someone in school (n = 178) and 18.4% reported fighting at least once in the previous two weeks (n = 73) Effect of the program on self-esteem No significant difference was found between the two groups at baseline for all the variables of self-esteem (F[5407] = 510; p = 769) The Pearson correlation was used to study the relationship between self-esteem and age Self-esteem was negatively correlated with the age of the adolescents (r = −.117; p = 017) Regarding total Self-Esteem score, the mixed ANOVA revealed a significant group-by-time interaction effect (F[1411] = 8.89; p = 003; ηρ2 = 021) Significant main Moulier et al BMC Psychology (2019) 7:82 Page of 10 effect of time (F[1411] = 6.31; p = 012; ηρ2 = 015) and main effect of group (F[1411] = 5.59; p = 019; ηρ2 = 013) were found There was no significant difference between the two groups at baseline (m(SD)Papillagou = 218.32(23.21) and m(SD)Control = 215.28(26.17); t411 = 1.091; p = 276), but there was a significant difference after the Program (m(SD)Papillagou = 218.85(25.13) and m(SD)Control = 209.18(28.56); t411 = 3.197; p = 001) Regarding different Self-Esteem dimensions, MANOVA revealed that the program had a significant overall effect on Self-Esteem scores (F[5407] = 2.938; p = 013; ηρ2 = 035), especially on the Physical Self score Table includes the means (SD) of Self-Esteem scores, as well as the MANOVA results for each Self-Esteem score (Wilks’Lambda test) Similar results were observed when age was introduced as a covariate in the analysis Effect of the program on well-being No significant difference in well-being was found between the two groups at baseline: mean (SD) Papillagou = 8.1 (2.5) and mean (SD) Control = 8.2 (2.6) (t411 = 453; p = 651) Between both assessment sessions, well-being improved in 44% of Papillagou group participants (versus 32% in the control group), remained stable in 19% (versus 15% in the control group) and decreased in 37% (versus 53% in the control group) There was a significant change in wellbeing between the two groups when using the chi-squared test (X2 (2) = 8.048; p = 018; Cramér’s V = 14) night (X2 (2) = 10.679; p = 001; Cramér’s V = 343), ii) feelings of depression (p = 019; Cramér’s V = 503), iii) feeling hopelessness about the future (p = 035; Cramér’s V = 357), and iv) a non-significant tendency for feelings of sadness (p = 056; Cramér’s V = 426; Table 3) Effect of the program on risk behaviors The frequency of risk behaviors in each group at baseline is reported in Table No significant difference was found between the two groups at baseline (chi-squared test) except for two items: i) spreading a rumor in school (X2(1) = 4.54; p = 033; and ii) stealing (X2(1) = 8.24; p = 004), with a higher frequency in the control group Among pupils reporting risk behaviors at baseline, either the chi-squared test or Fisher’s exact test was used to compare the improvement between the two groups after the second assessment After the Mission Papillagou program, adolescents showed a significant improvement in comparison with the control group in: i) spreading a rumor in school (X2 (1) = 10.656; p = 001; Cramér’s V = 440); ii) having been insulted in school (X2 (1) = 8.147; p = 004; Cramér’s V = 267) Regarding the consumption of toxic substances, the number of substance users per group was insufficient to conduct statistical analyses However, after the Mission Papillagou program, 57% of pupils no longer planned to smoke an electronic cigarette in the future, compared to 12% in the control group (Fisher Exact; p = 044; Cramér’s V = 372) Effect of the program on mood The percentage of adolescents in each group reporting symptoms related to mood at baseline is reported in Table No significant difference was found between the two groups at baseline when using the chi-squared test Among pupils reporting mood symptoms at baseline, either the chi-squared test or Fisher’s exact test was used to compare improvements in the two groups at the second assessment session After the Mission Papillagou program, adolescents showed a significant improvement in comparison with the control group in: i) waking up at Discussion The purpose of this study was to evaluate the impact of the Mission Papillagou program on self-esteem, wellbeing and risk behaviors among middle-schoolers The program was performed in the school environment over three separate three-hour sessions It is designed to ameliorate and strengthen young people’s life skills, thus developing protective factors against risk behaviors Our findings suggest an improvement in self-esteem, wellbeing, mood, and a reduction in some risk behaviors Table Effect of the program on self-esteem Self-esteem scores First Session Second Session Papillagou group Control group Papillagou group Control group Wilks’Lambda Mean (SD) Mean (SD) Mean (SD) Mean (SD) F(1,411) p-value Effect size ηρ2 Emotional self 44.43 (6.95) 43.46 (7.30) 44.46 (6.94) 42.32 (7.76) 2.73 p = 099 007 Social self 45.01 (5.83) 44.92 (5.52) 44.34 (6.08) 43.44 (6.91) 1.26 p = 263 003 Scholarly self 41.83 (8.65) 40.63 (9.27) 42.29 (8.66) 39.69 (8.56) 3.54 p = 061 009 Physical self 44.61 (7.80) 44.36 (9.39) 45.41 (7.89) 42.44 (8.89) 14.11 p < 001*** 033 Future self 42.44 (4.84) 41.92 (6.28) 42.35 (5.07) 41.29 (6.30) 0.73 p = 393 002 Legends Means and Standard deviations are reported for each group Bolded values indicate p ≤ 05 * p ≤ 05; ** p ≤ 01; *** p ≤ 001 Moulier et al BMC Psychology (2019) 7:82 Page of 10 Table Frequency and course of mood symptoms In the last weeks Papillagou group (n = 317) Control group (n = 96) Frequency at the first Percentage of Frequency at assessment ± 95% CI children who the first reported feeling assessment ± 95% CI better at the second assessment Percentage of Statistical value p-value children who reported feeling better at the second assessment Effect size Cramér’s V 078 Having trouble falling 24.61% ± 4.74 asleep at night (n = 78) 51.28% 27.08% ± 8.89 (n = 26) 42.31% X2 (1) = 628 428 Waking up at night 21.14% ± 4.49 (n = 67) 59.70% 25% ± 8.66 (n = 24) 20.83% X2 (1) = 10.679 001*** 343 Reproaching themselves about something 14.20% ± 3.84 (n = 45) 68.89% 16.67% ± 7.46 (n = 16) 43.75% X2 (1) = 3.176 075 228 Feeling lethargic 14.20% ± 3.84 (n = 45) 53.33% 8.33% ± 5.53 (n = 8) 75.00% Fisher exact 441 157 Being generally worried 10.09% ± 3.32 (n = 32) 53.13% 10.42% ± 6.11 (n = 10) 60.00% Fisher exact 1.000 059 Feeling depressed 7.26% ± 2.86 (n = 23) 69.57% 4.17% ± 3.98 (n = 4) 0.00% Fisher exact 019* 503 Feeling hopelessness about the future 10.73% ± 3.41 (n = 34) 73.53% 7.29% ± 5.20 (n = 7) 28.57% Fisher exact 035* 357 Feeling sad 7.57% ± 2.91 (n = 24) 66.67% 3.13% ± 3.48 (n = 3) 0.00% Fisher exact 056 426 Legends CI Confidence Interval Bolded values indicate p < 05 * p ≤ 05; ** p ≤ 01; *** p ≤ 001 among adolescents who took part in the program, compared with the control group The Mission Papillagou program significantly improved both the total self-esteem and Physical Self scores At the second assessment session, these mean self-esteem scores increased slightly in the Papillagou group, while they decreased in the control group Selfesteem is highly associated with body image in young people [23–26] Satisfaction with his/her own physical appearance can denote high self-esteem [23, 25, 26] In this study, the improvement in total self-esteem among adolescents who participated to the program could therefore be due to a more positive attitude toward their own physical appearance Although the topics covered during this program did not focus on physical appearance, role-play games allowed adolescents to act in front of their peers in order to develop selfacceptance and positive self-perception, while relativizing body changes related to puberty Moreover, some of the activities covered during the program, such as stating classmates’ qualities and receiving compliments from them, can improve self-esteem and promote better relationships with others In addition, according to our results, self-esteem may be negatively correlated with age, but this result should be considered with caution because of its weak magnitude (r = −.117) Nevertheless this would tally with other studies that reported a decline in self-esteem [27], particularly among 12 and 13 year-olds [28, 29], due to the physical and psychological changes experienced during puberty This suggests that the Mission Papillagou program could limit self-depreciation observed throughout adolescence Other life-skills programs have reported a positive impact on self-esteem among young people [30–32] For example, a French program called ESPACE, which focused on developing psychosocial skills and self-esteem in order to reduce the age of regular alcohol consumption among adolescents in middle schools, reported improved self-esteem (including self-confidence and body image) among adolescents who took part in the program compared to a control group [33] This program consisted of 43 h of intervention over three years However, the authors did not demonstrate a significant difference in alcohol consumption between both groups Low self-esteem has been shown to be significant in the etiology of psychiatric disorders such as depression and anxiety, as well as addictive disorders, particularly in adolescents and young adults [34] Since self-esteem plays a major role in the adaptation of the individual to his or her environment, it is a protective factor against risks related to adolescent development, including toxic substance consumption [34] Preserving self-esteem during early adolescence might have a long lasting effect, preventing the development of depressive symptoms in late adolescence and early adulthood Indeed, a large prospective cohort study by Masselink et al [35], which followed 2228 adolescents over several years, showed Moulier et al BMC Psychology (2019) 7:82 Page of 10 Table Frequency and course of risk behaviors Occured at least once during the last weeks Papillagou group (n = 317) Control group (n = 96) Frequency at the first assessment ± 95% CI Percentage of children reporting a decrease at the second assessment Frequency at the first assessment ± 95% CI Percentage of children reporting a decrease at the second assessment Statistical value p-value Effect size Cramér’s V Skipping school 18.93% ± 4.31 (n = 60) 36.67% 21.88% ± 8.27 (n = 21) 23.81% X2 (1) = 1.157 282 120 Arriving at school late 51.74% ± 5.50 (n = 164) 42.68% 58.33% ± 9.86 (n = 56) 35.71% X2 (1) = 839 360 062 Insulting someone in school 42.27% ± 5.44 (n = 134) 35.07% 46.875% ± 9.98 (n = 45) 28.89% X2 (1) = 578 447 057 Spreading a rumor around school 11.36% ± 3.49 (n = 36) 72.22% 19.79% ± 7.97 (n = 19) 26.32% X2 (1) = 10.656 001*** 440 Spreading a rumor on social networks 6.94% ± 2.80 (n = 22) 68.18% 6.25% ± 4.84 (n = 6) 33.33% Fisher exact 174 293 Physical fighting 17.67% ± 4.20 (n = 56) 58.93% 19.79% ± 7.97 (n = 19) 42.11% X2 (1) = 1.620 203 147 Stealing 6.31% ± 2.67 (n = 20) 45.00% 15.63% ± 7.26 (n = 15) 40.00% X2 (1) = 088 767 050 Doing something illegal 6.62% ± 2.74 (n = 21) 57.14% 9.38% ± 5.83 (n = 9) 44.44% Fisher exact 694 117 Bullying someone to obtain something 3.79% ± 2.10 (n = 12) 58.33% 6.25% ± 4.84 (n = 6) 66.67% Fisher exact 1.000 081 Have been insulted at school 26.50% ± 2.48 (n = 84) 53.6% 31.25% ± 9.27 (n = 30) 23.3% X2 (1) = 8.147 004** 267 Have been physically assaulted at school 6.31% ± 2.68 (n = 20) 75.00% 7.29% ± 5.20 (n = 7) 42.86% Fisher exact 175 299 Have been stolen from 7.89% ± 2.97 (n = 25) 76.00% 11.46% ± 6.37 (n = 11) 45.45% Fisher exact 124 298 Have been bullied into giving away something 4.73% ± 2.34 (n = 15) 66.67% 7.29% ± 5.20 (n = 7) 28.57% Fisher exact 172 356 Legends CI Confidence Interval Bolded values indicate p < 05 * p ≤ 05; ** p ≤ 01; *** p ≤ 001 that low self-esteem was a vulnerability factor for developing depressive symptoms Together with boosting self-esteem, the Mission Papillagou program also significantly improved well-being and mood, in comparison with the control group Mood is defined as a temporary state of mind, and is a component of well-being [36] Self-esteem is both a protective factor and a strong predictor of mood and well-being [11, 37] Life-skills based topics covered during the Mission Papillagou program, such as coping with stress and emotions, and developing better relationships with peers and adults, allowed adolescents to feel better about themselves and others Thus, there were improvements in both their well-being and their mood (including better sleeping patterns, fewer depressive feelings, and more feelings of hope) Other prevention programs reported an improvement in well-being and lower levels of distress among program participants compared to a control group [16] However, the ESPACE program, which aimed to promote self-esteem in adolescents, reported no difference in well-being, including current life satisfaction, feeling depressed, or feeling worried [33] Depression and feelings of unease in adolescents are of great cost to public health In early adolescence, the prevalence of depression is around 2%, and it increases throughout adolescence to reach about 18% in early adulthood [38] This program produced encouraging results to combat this, with a notably large effect size on depression However our results need to be tested in future research using validated scales of mood and well-being The Mission Papillagou program also resulted in a decrease in the frequency of risk behaviors, specifically insults and the spread of malicious rumors Verbal harassment and rumor spreading are part of bullying, which is a key contributor to global mental health issues [2] Being a victim of bullying is especially associated with depression, reduced self-esteem, and anxiety, as well as a probable contributor to alcohol, tobacco and illicit drug use [2] The effectiveness of the program on Moulier et al BMC Psychology (2019) 7:82 decreasing verbal harassment is therefore likely to improve mood, quality of life and self-esteem among potential victims of bullying However, the program’s effect on the spread of malicious rumors should be treated with caution, because the pupils in the Papillagou group spread less rumors than those in the control group at the first assessment Regarding the program’s effect on toxic substance consumption, the sample of consumers was not large enough to perform statistical analyses Nevertheless, the program induced a change of opinion toward the possibility of smoking an electronic cigarette in the future Our results are consistent with the ESPACE study, which reported a positive impact on self-esteem and psychosocial skills among pupils who took part in the program compared to a control group, but no difference regarding their consumption of toxic substances [33] This latter finding can be explained by the early age (around 15 years old) of the participants, an age at which regular use of toxic substances affects only a limited number of young people Compared to other prevention programs, Mission Papillagou has the advantage of being shorter (thus it is easier to incorporate into the school curriculum), and less specialized (i.e it does not focus on a single disorder) It addresses several issues by adapting to the specific problems encountered by the class Finally, it is important to note that the Mission Papillagou program did not have any negative effects on participants However our outcomes should be treated with caution because the effect sizes were mostly small (self-esteem, well-being, frequency of insults) or medium (“feeling hopelessness about the future”, “waking up at night”, rumor-spreading and smoking an electronic cigarette in the future), except for the depressive feeling variable, which had a large effect size This positive effect on mood may be explained by its lower inertia compared to more complex psychological concept, as self-esteem and well-being The latter might require more time to show a larger fluctuation The current study has some limitations First, as mentioned above, there was a low proportion of toxic substance users among participants This prevented any conclusion being drawn regarding the effect of the program on participants’ current toxic substance consumption A study on a larger number of subjects would have made it possible Secondly, regarding experimental design, schools were not randomly assigned in the Papillagou group or the control group for practical and organizational reasons, which could constitute a bias Nevertheless, the schools that took part in this study had very similar socio-economic profiles Moreover, participants and informants were not blind to study conditions Thirdly, the scale used to assess wellbeing was not validated A validated scale would have Page of 10 ensured greater reliability, and comparison with other studies To our knowledge, there has never been a validated French-language scale to assess well-being in adolescents Fourthly, days separating the two assessments were slightly different according to classrooms (depending on school holidays and availability schedule) In future studies, it would be better to control this factor more strictly Finally, the effect of the program was only assessed in the short term It would be more valuable to assess the impact of the Mission Papillagou program over a longer period, such as or years This project is currently under consideration, but it requires conducting a study with a larger cohort of children, because of high risk of lost to follow-up (move, change of school, school exclusion ) Conclusion This study confirms the probable benefits of implementing risk prevention programs that promote life skills Besides reducing risk behaviors, the Mission Papillagou program has a generally positive effect on young adolescents, especially on self-esteem, well-being and mood The implementation of this type of program in schools should therefore be encouraged Acknowledgments Thanks to Owen Thomas and Richard Haycraft for proofreading, and Clémence Isaac for her help designing Fig Authors’ contributions All authors read and approved the final manuscript VM, FT, ZB, YB, PAG, EM and DJ contributed to the conception and design of the study ZK, ZB, YB, NZ and EM participated especially in the creation and implementation of the Papillagou Program ZK, ZB, YB, NZ and AO made substantial contributions to the acquisition of data VM, HG, FT, ZK, ZB, YB, PAG, EM and DJ interpreted the results VM, HG and FT were the major contributors to data analysis and writing the manuscript Funding The Agence Régionale de Santé (ARS, Délégation Départementale de SeineSaint-Denis) and the Mission Métropolitaine de Prévention des Conduites Risque (MMPCR) financed this study Availability of data and materials The datasets used and analyzed during the current study are available from the corresponding author upon request Ethics approval and consent to participate The protocol complies with the ethical standards of the 1964 Helsinki declaration and its later amendments, and followed good clinical practice guidelines This pilot study took place from November 2015 to June 2016, before the Jarde law (2016–1537, 11/17/2016) came into effect Because this research was not biomedical, not interventional, and focused on an existing middle-school program, formal ethical approval was not required for this type of study, in agreement with Article 88 of Public Health Law (2004–806, 8/9/2004): for reference, see https://www.legifrance.gouv.fr The research protocol was reviewed and approved by each school principal Parents and children received clear, accurate and detailed information about the protocol, and gave written consent to participate Consent for publication Not applicable Moulier et al BMC Psychology (2019) 7:82 Competing interests The authors declare that they have no competing interests Author details Unité de Recherche Clinique, EPS Ville Evrard, Neuilly-sur-Marne, France Service hospitalo-universitaire de psychiatrie adulte, CH du Rouvray, Sotteville-lès-Rouen, France 3APCIS, Stains, France 4Agence Régionale de Santé (ARS), Délégation Départementale de Seine-Saint-Denis, Bobigny, France 5Mission Métropolitaine de Prévention des conduites risque, Pantin, France Received: November 2018 Accepted: 29 November 2019 References World Health Organization Growing up unequal : gender and socioeconomic differences in young people’ s health and well-being 2014 Moore SE, Norman RE, Suetani S, et al Consequences of bullying victimization in childhood and adolescence: a systematic review and metaanalysis World J Psychiatry 2017;7:60–76 Due P, Holstein BE, Lynch J, et al Bullying and symptoms among schoolaged children: international comparative cross sectional study in 28 countries 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